eMedicine Specialties > Pediatrics: Surgery > General Surgery

Duodenal Atresia and Stenosis: Surgical Perspective: Treatment

Author: Nicola Lewis, MBBS, FRCS, Specialist Registrar, Department of Surgery, Birmingham Children's Hospital, UK
Coauthor(s): Philip Glick, MD, MBA, Professor, Departments of Surgery, Pediatrics, and Gynecology and Obstetrics, Vice-Chairperson for Research and Development, Department of Surgery, State University of New York at Buffalo
Contributor Information and Disclosures

Updated: Oct 1, 2008

Treatment

Surgical Therapy

The operative management of duodenal atresia is determined by the anatomic findings and associated anomalies noted upon laparotomy. Bypass procedures for duodenal atresia or stenosis include duodenoduodenostomy or duodenojejunostomy. Type 1 duodenal atresia can also be managed by simple duodenotomy with web excision.

Preoperative Details

Orogastric decompression of the stomach and fluid resuscitation should be promptly initiated. Orogastric losses are monitored and replaced. Broad-spectrum antibiotics and 1 mg vitamin K are administered. Parenteral nutrition is instituted on the first day of life via a peripherally inserted central catheter. When stable, the infant is taken to the operating room.

Intraoperative Details

  • Following precautions against hypothermia, the abdomen is entered via a transverse right upper quadrant incision. The stomach and first part of the duodenum are usually dilated and thickened and require decompression via the orogastric tube.
  • The gallbladder and spleen are examined. The viscera are examined for other anomalies, including malrotation, an anterior portal vein, and an annular pancreas. The liver is padded and gently retracted superiorly.
  • The duodenum is mobilized via Kocher maneuver.
  • The site of obstruction is detected by the discrepancy in the size of the bowel above and below the obstruction and by passing the orogastric tube down to the level of the obstruction.
  • In patients with a windsock web, an indentation at a site proximal to the site of obstruction may be observed. This marks the site of origin of the web and the location where the duodenotomy should be made.
  • The papilla of Vater is identified following duodenotomy by gently pressing on the gallbladder and observing the proximal and distal segments. In patients with type 3 defects, dual biliary ducts may be present.
  • Following documentation that no distal obstruction is present, proximal transverse to distal longitudinal (diamond-shaped) anastomosis may be performed using interrupted stitches (see Media file 3). A direct duodenoduodenostomy is believed to result in a relatively earlier recovery of anastomotic function when compared with results following duodenojejunostomy.7 During the diamond-shaped anastomosis, the midpoint of the proximal incision is approximated to the end of the distal incision.4 This creates a larger stoma and allows the proximal duodenum to overlie the distal duodenum. As an alternative, a standard side-to-side duodenoduodenostomy may be performed.
  • Alternatively, type 1 defects may be treated by excising the web. An anterior duodenotomy is performed, and the web is opened along the lateral side. The web is carefully excised, leaving the medial portion containing the papilla in situ.
  • When the proximal duodenum is floppy and dilated, an antimesenteric duodenoplasty may be performed either by excising excess tissue or by plicating the anterior wall with interrupted sutures over a dilator. This is believed to decrease the complications of a megaduodenum.20
  • If an annular pancreas is present, it should not be divided. The anastomosis is formed anterior to the pancreatic mass.
  • In patients with malrotation, a Ladd procedure is performed; Ladd peritoneal bands are divided, the small bowel mesentery is widened, an appendectomy is performed, and the cecum and colon are placed on the left.

Postoperative Details

The orogastric tube is left on free drainage. The patient is not given oral feedings until bowel sounds are heard, stool is passed, and the gastric drainage is limited (<1 mL/kg/h of clear or pale-green fluid). This may take 7-10 days but can be prolonged in the premature infant with other significant anomalies that require venous access for parenteral nutrition. 

Oral feedings are gradually introduced, commencing with clear fluids and aspirating the stomach prior to each feed. These infants can be placed right-side down after feeds to enhance gastroduodenal emptying.

Follow-up

Poor peristalsis in the proximal duodenum leads to functional obstruction in some patients. This may predispose the patient to blind loop syndrome and duodenogastric reflux. Alkaline biliary reflux leads to gastritis and peptic ulceration.

Reports of functional obstructions occurring more than 2 decades after primary repair suggest that survivors of duodenal atresia should receive the following long-term follow-up care:

  • Clinical examination: Special attention is paid to the abdominal examination and the nutritional status of the patient.
  • Radiologic examination: A barium meal may demonstrate the following:
    • Mildly dilated duodenum
    • Megaduodenum
    • Delayed emptying
    • Diminished peristalsis
    • Slight luminal narrowing
    • Bezoars
  • Endoscopy: Findings on esophagogastroduodenoscopy include the following:
    • Esophageal irritation
    • Reflux gastritis
    • Megaduodenum
    • Delayed emptying

Complications

Early postoperative complications are frequently related to prematurity, coexisting congenital anomalies, and parenteral nutrition. Intestinal obstruction secondary to adhesions may also occur in the early postoperative period.

Long-term complications occur at any time from a few months to years following the primary procedure. Hence, long-term follow-up is compulsory for infants treated for intrinsic duodenal obstruction. Late complications include the following:20,21,22

More on Duodenal Atresia and Stenosis: Surgical Perspective

Overview: Duodenal Atresia and Stenosis: Surgical Perspective
Workup: Duodenal Atresia and Stenosis: Surgical Perspective
Treatment: Duodenal Atresia and Stenosis: Surgical Perspective
Follow-up: Duodenal Atresia and Stenosis: Surgical Perspective
Multimedia: Duodenal Atresia and Stenosis: Surgical Perspective
References
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References

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Further Reading

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Keywords

duodenal atresia, stenosis, congenital duodenal obstruction, gastrojejunostomy, duodenojejunostomy, duodenoduodenostomy, duodenoplasty, intrinsic duodenal obstruction, high intestinal obstruction, upper intestinal obstruction, sustained vomiting, bilious vomiting, nonbilious vomiting, loss of fluid, loss of electrolytes, hyperalimentation, Down syndrome, esophageal atresia, malrotation, anterior portal vein, second distal web, anorectal anomalies, intestinal atresias, cloacal anomalies, renal tract anomalies, polyhydramnios, choledochal cyst, failure to thrive

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Contributor Information and Disclosures

Author

Nicola Lewis, MBBS, FRCS, Specialist Registrar, Department of Surgery, Birmingham Children's Hospital, UK
Disclosure: Nothing to disclose.

Coauthor(s)

Philip Glick, MD, MBA, Professor, Departments of Surgery, Pediatrics, and Gynecology and Obstetrics, Vice-Chairperson for Research and Development, Department of Surgery, State University of New York at Buffalo
Philip Glick, MD, MBA is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Thoracic Society, Association for Academic Surgery, Association for Surgical Education, Central Surgical Association, Federation of American Societies for Experimental Biology, Medical Society of the State of New York, Phi Beta Kappa, Physicians for Social Responsibility, Royal College of Surgeons of England, Sigma Xi, Society for Pediatric Research, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, and Society of University Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Robert K Minkes, MD, PhD, Professor of Surgery, University of Texas Southwestern; Chief of Surgical Services, Children's Medical Center of Dallas-Legacy
Robert K Minkes, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Andre Hebra, MD, Chief, Division of Pediatric Surgery, Medical University of South Carolina; Professor of Surgery and Pediatrics, Medical University of South Carolina
Andre Hebra, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, Association for Academic Surgery, Society of Laparoendoscopic Surgeons, South Carolina Medical Association, Southeastern Surgical Congress, and Southern Medical Association
Disclosure: Nothing to disclose.

CME Editor

H Biemann Othersen Jr, MD, Professor of Surgery and Pediatrics, Emeritus Head, Division of Pediatric Surgery, Medical University of South Carolina
H Biemann Othersen Jr, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Association for the Surgery of Trauma, American Burn Association, American Cancer Society, American College of Surgeons, American Medical Association, American Pediatric Surgical Association, American Society for Parenteral and Enteral Nutrition, American Surgical Association, American Thoracic Society, British Association of Paediatric Surgeons, Society for Surgery of the Alimentary Tract, Society of Critical Care Medicine, South Carolina Medical Association, Southeastern Surgical Congress, Southern Medical Association, Southern Society for Pediatric Research, and Southern Thoracic Surgical Association
Disclosure: Nothing to disclose.

Chief Editor

Marleta Reynolds, MD, Professor of Surgery, Feinberg School of Medicine, Northwestern University; Interim Head, Division of Pediatric Surgery, Department of Surgery, Children's Memorial Hospital of Chicago
Marleta Reynolds, MD is a member of the following medical societies: American Pediatric Surgical Association
Disclosure: Nothing to disclose.

 
 
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